Psychoactive substances are drugs or chemicals that have an effect on the central nervous system (CNS). The National Institute of Drug Abuse defines drug abuse or drug dependence as a condition in which the use of a legal or illegal drug causes physical, mental, emotional, or social harm. Drug usage impairs one’s ability to function in daily activities of living and in work environments. Relationships with family and friends become impaired and dysfunctional.

Most of the abused drugs fall into two main categories, CNS depressants and CNS stimulants. CNS depressants include narcotics, sedatives, barbiturates, tranquilizers, and inhalants. The desired effect by the user is a sense of increased self-esteem, euphoria, relaxation, and relief from pain and anxiety. CNS stimulants include amphetamines, hallucinogens, and cocaine. The desired effect by the user is a sense of well-being, alertness, excitation, overconfidence, and increased initiative.

Tolerance to the drug results in the need for increasing amounts, and the physiological and psychological dependence on the drug leads to maladaptive behaviors. Attempts to discontinue or control use of the drug lead to withdrawal symptoms, which, if left untreated, can range from feeling flulike symptoms to coma and possibly death. The withdrawal from a drug produces feelings and sensations opposite of the effects produced by using the drug. Withdrawal can be treated to avoid withdrawal symptoms. Chronic abuse of psychoactive substances may lead to complications, including pulmonary emboli, respiratory infections, trauma, musculoskeletal dysfunctions, psychosis, malnutrition disturbances, gastrointestinal disturbances, hepatitis, thrombophlebitis, bacterial endocarditis, gangrene, and coma.

The cause of substance abuse is complex and involves many factors, including the type and availability of the drug, personality type, environmental factors, peer pressure, coping abilities of the individual, genetic factors, and sociocultural influences. Cocaine dependence is thought to be associated with a deficiency in dopamine and norepinephrine neurotransmitters. Use of narcotics and opiates may interfere with the biochemical factors that are related to the body’s own production of opiate-like substances.

A psychological factor that seems common to all forms of substance abuse is low selfesteem. Also found are feelings of inadequacy, loneliness, shame, and guilt that lead to depression and a sense of hopelessness and despair. Sociocultural factors have significant influence. Increasing numbers of individuals experience family breakup and separation, school failure, poverty, unemployment, “living in the fast lane,” and stressors related to highly competitive work environments. Teenagers and young adults often begin experimenting as a result of peer pressure and the easy availability of drugs.

Nursing care plan assessment and physical examination

The physiological signs and symptoms of use or intoxication vary, depending on the substance. Consequently, when a person is admitted in an intoxicated state or in withdrawal, it is important to know what drug or drugs have been used, the route used, and if possible, the amount of drug used. Determine if alcohol is also being used because there is a synergistic effect that increases the effect of both drugs. Some patients may be misusing and abusing psychoactive drugs through ignorance. Others may have begun using them as part of a physician-prescribed treatment regimen and then became addicted. If the individual is unable to give a history because of overdose, friends or family members may provide needed information and clothing can be checked for drug paraphernalia. Elicit a history of previous detoxification treatments, effectiveness, length of recovery, and what influenced a return to drug usage.

If the patient is admitted with intoxication and a drug history cannot be obtained, signs and symptoms can be indicators of the type of drug used. Inspect the patient for evidence of how the drug is used, such as needle marks from mainlining, nasal irritation caused by snorting, ulcerations on lips and tongue from chewing, cellulitis from injecting drugs and missing the vein, and infections from sites used for mainlining.

Obtain information on how the patient perceives the effect drugs have on her or his life, work, and the relationship with family and friends. Identify strengths and limitations. Assess the patient’s emotional state before admission, especially noting depression and thoughts about suicide. If the patient is involved in a relationship, determine the degree of stability. Ask whether the partner uses drugs and what her or his attitude is toward the patient’s drug use. If the patient is a parent, find out the children’s ages and investigate how the children are affected by the patient’s drug use.

Elicit an employment history, including the type and length of employment. Determine how the use of drugs has affected the patient’s work. Determine how much time off from work has been caused by the drug use. Establish a history of the financial effects of the drug use; ask how much the patient spends on drugs and if he or she has developed other sources of income besides his or her job. Determine how the use of drugs has affected the patient’s financial resources.

The immediate goal after depressant ingestion is to keep the individual safe during a drug overdose or withdrawal. The long-term goal is for the patient to remain drug-free. In the acute phase, the immediate effects of narcotics can be reversed with naloxone (Narcan). In the case of barbiturate overdose when the patient is conscious, mild intoxication can be treated by letting the individual “sleep it off.” More severe cases of overdoses need to be handled in an acute or critical care environment where continuous monitoring can occur. Of paramount importance is to make sure the patient has adequate airway, breathing, and circulation during the time period that depressants may lead to severe respiratory depression.

Generally, if the patient is unconscious and the substance is unknown, the following steps are taken in management: (1) Begin supplemental oxygen; (2) insert intravenous line with saline infusion or dextrose in water; (3) administer dextrose, thiamine, and naloxone; (4) protect airway with endotracheal intubation; (5) pass orogastric tube, lavage, and administer activated charcoal; (6) admit the patient for ongoing observation and management. Activated charcoal is produced from the destructive distillation of organic materials. The substance absorbs toxic substances because of large external pores and a large internal surface area that binds with toxic ions. A cathartic such as magnesium citrate is given to help gastrointestinal excretion of the toxic substance bound with activated charcoal. Activated charcoal is also given for overdoses when the substance is known, such as phenobarbital, carbamazepine, cyclic antidepressants, amphetamines, and cocaine.

Management of stimulants can be similar to that of depressants, with the administration of activated charcoal. Seizures are a possibility in the case of an overdose with stimulants, but note that amphetamines and cocaine have a short duration time of 2 to 4 hours. Phenytoin (Dilantin) can be ordered to prevent seizure activity, and benzodiazepines are also used to treat agitation or seizures. External cooling may be used to reduce hyperthermia, and intravenous fluids may be used to replace fluid loss and to prevent myoglobin damage in the kidneys. All patients with substance abuse and overdoses need counseling and therapy to manage their substance use patterns.

During the acute phase, keep the patient safe. Use strategies for continuous monitoring of airway, breathing, and circulation, and implement emergency measures as needed to support life. Monitor for seizure activity and place the patient on the seizure precautions regimen. Examine the environment for safety risks such as falls from the bed or self-discontinuation of tubes. Assess the potential for a suicide attempt, and if necessary, initiate suicide precautions and never leave the patient unattended.

Meet the self-care deficits related to hygiene, nutrition, and elimination. Promote a sense of security: approach the patient in a calm, nonthreatening, and nonjudgmental way. Building a trusting relationship with the patient provides a foundation for addressing the more long-term goals that are associated with becoming drug-free.

Following the acute phase, initiate the process of rehabilitation, and implement a treatment plan to maintain abstinence. The first goal is to work toward getting the individual to break through the denial of drug abuse and take responsibility to begin the recovery process. Provide educational materials and arrange a consultation with a chemical abuse counselor to begin the process before discharge from an acute care setting. Often, individuals are admitted from an acute care setting to an inpatient or outpatient treatment facility where nursing staff and other healthcare providers can begin specialized treatment programs. These programs include peer group programs in which confrontation, support, and hope are part of the treatment process. Treatment goals for the individual include development of a healthy self-concept, self-discipline, adaptive coping strategies, strategies to improve interpersonal relationships, and ways of filling leisure time without the use of drugs.

The patient should be discharged to an inpatient or outpatient treatment program to address the long-term effects of substance abuse. After discharge from a treatment program, the individual may continue with groups such as Narcotics Anonymous (NA), Cocaine Anonymous (CA), or Alcoholics Anonymous (AA). Family dynamics often play a role in the use of drugs. It is important for the family to be involved in the treatment plan through individual and family therapy and support groups that address issues dealing with family members who abuse drugs.